Infant Cereal Program in Nunavut_ What Can We do Better_ - UQAT

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Infant Cereal Program in Nunavut_ What Can We do Better_ - UQAT Powered By Docstoc
					  Infant Cereal Program
       in Nunavut:
 What Can We do Better?
          Vesselina Petkova, RD
         Territorial Coordinator,
Canada Prenatal Nutrition Program (CPNP)
• No disclosures or conflicts of interest
• Will discuss process, barriers, and some
  outcomes related to infant cereal program
• Project in progress
  – Not an example of a perfect program
  – Sometimes more questions than answers
  – Share with you and get feedback
   What is Iron Deficiency Anemia
• When low iron in the system = iron deficiency anemia (IDA)
   – Ferritin is the measure of body’s iron storage
   – Low iron store if ferritin < 12 ng/mL

• Lack of iron interferes with ability to create haemoglobin (Hg)
   – Anemia when Hg less than 2 s.d.
   – Usually when Hg < 110 g / L

• Hg responsible for distributing oxygen                       to
  tissue, including heart and brain

                                                       ᐊᐅᐸᖅᑐᑦ ᐊᐅᑦ
          Why does IDA matter
• Negatively affects billions worldwide
• Affects cognition, psychomotor development,
  work productivity and community capacity
• High economic burden
  – Highest costing disease (other than TB)
• Generally preventable
• Damage caused by IDA can be permanent if not
  reversed early
 Infant Risk factors for IDA include:
• Pregnancy outcomes (mothers’ anemic, low birth
  weight, premature infants)
• Rapid growth – infancy (6-24 m.o.)
• Nutrition behaviours / poor intake of iron:
  – Early discontinuation of breastfeeding
  – Poor nutritional status (food insecurity, low SES)
  – Low iron formula
  – Excessive / early cow’s milk intake
  – Delayed / improper introduction of solids
     Is it a problem in Nunavut?
• At least 250 cases of anemia in children (0-
  5) managed and treated annually.
  – ~ 50 cases per 1000 children/year (~ 5 %)
• True burden of the disease?
  – Vast majority of patients are asymptomatic.
  – Tip of the iceberg phenomenon
     Many more unknown cases?
• Population screening provides proper prevalence.
   – No screening protocol implemented across the Territory.
• Prevalence in Igloolik:
   – 48% had anemia
   – 28% had IDA - up to 8 x national averages!
   – 53% depleted iron stores

                                         Christofides 2005
         Infant Screening in Iqaluit
• 6 m.o. - 5 y.o.
• 2006 – May 2010
• N = 677, but 1291 readings
70% of anemia is mild
Anemia by age group

     Age in Months
       Iqaluit Anemia Screening
• Prevalence rates are very high
  – Highest at 8 – 11 months.
  – If analysis is limited to infants < 24 months, then
    42.7% of infants were anemic.
  – Majority is mild.
  – But 17% of the children had at least one reading
    below 100 g/L (moderate anemia)
              Venous Draws
• Only 53 / 118 (~45%) patients went for venous
  blood work to confirm diagnosis

• 30% of those who went for blood work did not
  have a ferritin done to establish iron storage
     Infant Cereal Supplementation
1.   Context and Background
2.   Plan
3.   Process
4.   Outcomes and Feedback
Objective: Reduce the Prevalence of IDA
in Infants and Children
• Step 1: identify IDA as a                   public
  health priority
  – “By 2013, the rate of anemia in infants
  and toddlers will be halved”
• Step 2: commit to a focused strategy in order to
  address it
  – IDA program
Nunavut Iron Deficiency Anemia Project
Evaluation Strategy 2008
 Food-Based Intervention Options
   Considered ease of implementation, safety
   profile of a product, cost, and availability.
1. Fresh meats, including country food
2. Jarred meats distribution
3. Infant cereal distribution
4. Vitamin supplementation
                   Project Goals
1.   Provide iron-fortified infant cereal to Nunavut infants
     from 6-12 months of age, in quantity sufficient to
     meet the Recommended Dietary Allowance of 11
     mg/day for iron.
2.   Deliver cereal to infants via collaboration between
     community-based CPNP projects and Health Centers
3.   Determine if iron-fortified infant cereal is acceptable
     to mothers and infants.
1st phase: 2009-2010
• Provision of cereal
  – Through CPNP community based programs, with
    support of local Health Centers
  – 15 communities around Nunavut
• Order and distribution of cereal
  – Partnership with Northwest Company
            Cost and Funding
• Need: average of 3 boxes per month per child
  x 6 months
• Cost of cereal: ~ $5/box (incl. shipping)
• ~ $ 90 per child
• Total cost: $60,000 provided by CPNP
  – CPNP workers’ time and wages not included
Educational information
        Evaluation of 1st Phase
• Feedback from CPNP workers and mothers
  who received cereal.
• Process:
  – # of boxes of cereal distributed
  – # of users & who used cereal
  – perspective of CPNP workers
• Acceptability of cereal
• All 15 communities received cereal.
• Very few provided detailed information on
  – Systematic tracking wasn’t implemented
  – Some workers simply stated – ‘most’ distributed
• Also not clear on the number of users
• Unexpected issues related to program success
  such as Heinz recall of unrelated product
     CPNP Workers’ Perspective
• Most centers found the program easy to
• A request for ‘not so much paper work’
  – Asked to track how many users and how many boxes
    distributed at a time
• “I got it but never opened it… I didn’t know
  what to do with it”
     CPNP Workers’ Perspective
• There was a major stress with where to keep
  the cereal stock
• General request for fewer boxes
  – Knowing there is an expiry date
  – Feeling responsible for complete distribution
       Acceptable to Children?
• 50% like, 30% neutral, 20% dislike taste
  – Some mothers say children won’t eat it
  – “My child doesn’t like the flavor, can we get
• 50% of mothers admit to sharing cereal
  with other members of household
  – Typically sibling outside age group
       Acceptable to Mothers?
• 100% mothers support CPNP program to
• 75% would purchase cereal if available
Feedback from CPNP workers:
  – “some mothers feel uncomfortable taking the
    cereal… almost implying they were poor and
    couldn’t afford the cereal”
  – Felt that some mothers used it but not as the
    predominant infant food source
• Iron fortified infant cereal is one part of
  decreasing iron deficiency anemia amongst
• Program helps with broader goals of food
• Accepted by most mothers and infants
• General support for program and its continuation
                 Next Steps
• Fully implement cereal program
  – In all communities
  – Integrated in regular CPNP programming
  – Address barriers (storage, summer break...)
• Continue to develop education and
  communication strategy
• Evaluate health outcomes
  – implementation of screening program
                Next Steps
• How to better integrate program with
  health centre?
• How to integrate with local store?
• Are there locally sustainable options using
  country food?
• What to do with anemia that is NOT iron
Thanks to:
CPNP community workers
Mothers who provided feedback
V. Avinashi
S. Zlotkin
Public Health Nutritionists
R. Jetty
G. Osborne


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